Medical and Dental Benefits as contracted by the Amarillo Hospital District

January 1999

Wyatt Health Plan Overview
Policy of the Amarillo Hospital District
Eligibility Guidelines
Proof of Household Size/Identification
Proof of Residency
Proof of Income
Resources
Summary of Benefits
Hospitalization Benefits (NWTHS)
Outpatient Benefits
Dental Services Provided
Services Not Covered By the Amarillo Hospital District
Wyatt Health Plan Locations

WYATT HEALTH PLAN OVERVIEW

The Amarillo Hospital District (AHD) was established by House Bill 70 of the 56th Legislature of Texas to provide healthcare to the indigent residents of the Amarillo Hospital District. The benefits of the Amarillo Hospital District Plan are effective only if you complete the application for acceptance into the plan, are determined to meet the eligibility guidelines for coverage, and receive notification that you have been accepted into the plan and are now covered. You must remain covered in accordance with the rules of eligibility.

The costs of the benefits of this plan are paid by Northwest Texas Healthcare System (NWTHS), from revenues generated from other patients and from annual receipt of funds from the Amarillo Hospital District. The benefits are determined in accordance to the guidelines established by the Board of Managers of the Amarillo Hospital District. NWTHS has developed the Wyatt Health Plan through which these services are provided.

This booklet serves as a description of the benefits provided by the Wyatt Health Plan, and supersedes any and all previous material and descriptions issued to you by any employee or agent.

Michael A. Callahan
CEO/Managing Director
Northwest Texas Healthcare System

POLICY OF THE WYATT HEALTH PLAN

1. Hospital care of Members (qualified indigents) shall be provided in facilities contracted with NWTHS only, except as noted below.

2. Medical and dental treatment of non-hospitalized Members shall be delivered at ambulatory facilities of NWTHS unless specifically pre-approved by the NWTHS Administration.

3. The Wyatt Health Plan shall seek optimal, cost-effective alternatives for treatment.

4. Payments will not be made for the transfer or delivery of medically necessary services rendered outside the NWTHS contracted facilities, unless NWTHS Administration specifically authorizes such services.

5. The term "Member" (qualified indigent) of the Wyatt Health Plan has the following meaning:
a) The Member shall have their only place of abode within the Amarillo Hospital District. (The Amarillo Hospital District encompasses the whole of the City limits of Amarillo and all of Potter County. Only that part of Randall County within the Amarillo City limits is within the Amarillo Hospital District.)
b) The Member is not eligible for any Federal, State, regional or local program for assistance. If eligible for Medicaid and accepted in the Medicaid program, Member will be eligible to receive benefits from the Wyatt Health Plan only when such benefits are not benefits of Medicaid. If accepted into the Medicare program, Member will be eligible to receive benefits from the Wyatt Health Plan only when such benefits are not benefits of Medicare. Copayments and deductibles due under the Medicare program are benefits of the Wyatt Health Plan.
c) The financial requirements apply to any and all persons legally responsible for the patient. All such persons must apply and qualify.

i. If legally competent, the client shall formally request in writing to be a Member.

ii. If client is a minor, mentally incompetent, physically incapable or in legal custody, a form request in writing to be a Member shall be executed by a parent, guardian, nearest relative, custodian or conservator.

6. To be considered a Member the following income resource criteria will apply:
a) The base annual income allowance is determined by the Federal Poverty Guidelines

Income: Base annual income refers to total cash receipts before taxes, from all sources. These include money, wages, lump sum payments, settlements and salaries as described in the County Indigents Health Care Rules and Regulations of Senate Bill 1 of the 69th Texas Legislature.

Allowance: The dollar amount of income which may be retained before any funds are considered available for medical expenses.

b) In order for medical expenses to be paid, the value of personal property and equity in property or real estate must total $5000 or less. Furnishings in a household, household articles, clothing and tools are excluded from the calculation of equity.
c) The Member is unable to borrow sufficient funds to pay medical and/or hospital bills in whole or in part.
d) Persons whose income and/or equity exceed the base will be requested to partially pay for each visit for any inpatient or outpatient service. Table of Partial Payment will be between 100% and 150% of the Federal Poverty Guidelines.

7. The determination of whether a person is qualified as a Member of the Wyatt Health Plan will be made within 14 days of the completion of an application.

8. It is the responsibility of the Member or Member's approved representative (as defined in this agreement) to initiate renewal of eligibility of the Wyatt Health Plan. Failure to renew eligibility will result in termination from membership in the Plan, and, therefore, all benefits will cease.

9. At the time the Member no longer meets the necessary qualifications, that person will immediately become responsible for medical and hospital payments.

10. Medical services provided must be medically necessary services provided by a NWTHS contracted or pre-approved physician, nurse, or other licensed practitioner of the healing arts, within the scope of their practice, credentials and State law, to treat disease disability, or other adverse health conditions or their progression.

11. Medically necessary dental services will be those services provided by a NWTHS contracted or pre-approved dentist, oral surgeon, or other licensed practitioner of the dental health arts, determined to be the treatment of choice or an essential part of an overall treatment plan for a medical condition as determined by a physician or nurse practitioner in consultation with a dentist.

12. Persons determined to have moved to the Amarillo Hospital District boundaries for the sole purpose of becoming a Member are not eligible.

In order to determine eligibility, you must provide information and documentation on at least one item from each category of the following items. You may be required to produce provide information and documentation on more than one item.

PROOF OF HOUSEHOLD SIZE/IDENTIFICATION

• Birth Certificate(s)
• Social Security Card(s)
• Driver's License(s)
• Official Identification
• Place of Employment With a Picture
• Voter Registration Card(s)

PROOF OF RESIDENCY

• Property Tax Receipt
• Mortgage Payment
• Rent Receipt
• Utility Bill
• Business Mail Addressed to the Applicant
• Statement From a Reliable Source

PROOF OF INCOME

• Earning Statement From Employer
• Paycheck or Paycheck Stubs
• Pension Award Letter
• Disability Award Letter or Check
• Unemployment Compensation Award Letter or Check
• Retirement Check
• Military Allotment Check
• Self-Employment Bookkeeping
• Federal Income Tax Return
• Social Security Award Letter or Check
• Veterans Administration Benefit Pension
• Workers Compensation
• Child Support
• Aid for Dependent Children

RESOURCES

• Automobile Registration
• Checking Account Record
• Savings Account Passbook
• Property Tax Notice or Receipt
• Lump-Sum Payments
• Alimony
• IRAs or CDs

Wyatt Health Plan eligibility is approved for varying periods of time, based on each patient's determination.

It is the responsibility of the member or approved member's representative (as defined in this agreement) to apply for Wyatt Health Plan Coverage, and if approved, to renew their eligibility before their eligibility expires.
All benefits, including oxygen therapy and medical services will be discontinued if renewal is not accomplished.

Your application for medical assistance through the Wyatt Health Plan is also being considered for the following programs:

CIHCP (County Indigent Health Care Program)
CIDC (Chronically Ill and Disabled Children)
Medicaid
Texas Rehabilitation Commission
Title V Programs
Other programs for which you may be eligible

The Wyatt Health Plan, whose benefits are determined in conjunction with the Amarillo Hospital District, is a payor of last resort. Failure to complete application to all other sources for which applicant may be eligible will result in Wyatt Health Plan benefits being denied or canceled.

Individuals committing fraudulent acts to qualify for eligibility to become Members of the Wyatt Health Plan may have their eligibility to receive benefits terminated and criminal charges may be filed against such individuals.

SUMMARY OF BENEFITS

It is the adopted policy of the Amarillo Hospital District Board of Managers to furnish Members with coverage for his or her medical needs as identified by the medical staff and approved by the Review Organization. The Wyatt Health Plan has been designed to adhere to this policy. It is hoped that medical needs of patients and patient's personal desires are the same; however, if conflict exists, the patient will be offered the care recommended by the attending physician and determined to be medically necessary. Should the patient desire other than what has been determined to be medically necessary, he or she is advised that the Wyatt Health Plan will not assume responsibility for that care.

Elective services provided by contracted physicians, non-contracted physicians, hospitals, agencies, or facilities outside of the Amarillo Hospital District require pre-approval of the Review Organization and/or NWTHS Administration. Charges for such services will not be paid unless a written referral is initiated prior to the date of service.

HOSPITALIZATION BENEFITS (NWTHS)

• Semi-private hospital room and board, (private hospital room is a benefit only when under direct order of attending physician or for convenience of hospital.)
• Use of operating rooms and recovery areas
• Use of delivery rooms
• Use of Intensive and Special Care units
• General nursing care
• Maternity and newborn care
• Laboratory examinations for the diagnosis and treatment of medical conditions
• Diagnostic Imaging services
• Drugs and medicine on NWTHS Formulary List for use in the hospital
• Anesthesia and use of anesthesia equipment
• Oxygen and use of equipment for its administration
• Physical and Occupational Therapy and Rehabilitation Services provided by NWTHS and facilities contracted with the Amarillo Hospital District.
• Plaster casts, dressings and other special treatments
• Dietary services
• Psychiatric services
• Chemical and substance abuse services.

OUTPATIENT BENEFITS

• Podiatry services (does not include nail trimming, or cutting or removal of corns)
  Outpatient health services
• Services of nurses, physicians, nurse practitioners, surgeons, specialists and allied health professionals contracted with NWTHS
• Northwest Texas Hospital services required for medical or surgical diagnosis or treatments
• Use of NWTHS ambulatory surgical facilities and services
• With the following conditions, pharmaceutical services for medically necessary drugs on the Northwest Texas District Clinic Formulary List
• Drugs not on formulary require Medical Director or Indigent Care Coordinator approval
• Drugs and medicine must be prescribed by Wyatt Health Plan physician or nurse practitioner or an appropriately credentialed dentist or physician
• The prescription shall be limited to a 30 or 60-day supply, depending on medication
• Non-prescription drugs and medicines may be provided as an alternative to prescription drugs for the treatment of medical conditions.
• Blood transfusions, including the cost of blood and blood products
• Radium, X-rays and nuclear medicine services
• Physical therapy which is not a maintenance regimen, for a maximum number of 20 visits per calendar year
• Dietary counseling
• Treatment of medical conditions of the eye
• Surgical dressings, splints, casts and other consumable items
• Voluntary sterilization as outlined in the Medicaid guidelines
• Persons under 21 years of age, mentally incompetent or institutionalized are excluded and will not be considered for a tubal ligation or a vasectomy without a court order or permission of the legal guardian.
• Rental of contracted durable medical equipment, as authorized by the Medical Director or Indigent Care Coordinator upon orders by the primary care physician.
• Purchase of medical equipment requires Medical Director or Indigent Care Coordinator approval.
• Non-contract items require Medical Director or Indigent Care Coordinator approval.
• Emergency medical services only when the sudden onset of a medical condition is of such severity that the absence of immediate medical attention could result in placing the Member's health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.
• Prostheses and appliances may be provided, if necessary to prevent serious complications of a medical condition. Approval of the Medical Director or Indigent Care Coordinator is required.
• Dialysis
• Therapeutic radiology and/or chemotherapy for proven malignancy, if standard of care.
• Emergency transportation from one facility to another facility must be authorized by one of the following:Wyatt Health Plan Medical Director, Review Organization Indigent Care Coordinator, or a Health Administrator.
• Pain Clinic services, if approved by the Medical Director or Indigent Care Coordinator, on recommendation of attending physician.
• Removal of benign skin lesions, if approved by the Medical Director or Indigent Care Coordinator and if considered to have potential for malignancy.
• Treatment for the basic conditions of alcoholism or drug addiction.
• Orthotic and prosthetic devices, on recommendation of attending physician Medical Director or Indigent Care Coordinator pre-approval required.

DENTAL SERVICES PROVIDED

Amarillo College dental hygiene services are available for preventative dental cleanings and hygiene instruction once a year for Members.

Adults 18 or older:
Services offered by the Dental Clinic are limited to acute care for adults which is necessary for the management of pain. Rehabilitation needs are referred to the Texas Rehabilitation Commission (currently on South Western Street) for evaluation.

Children under 18:
The Wyatt Health Plan recognizes the need to provide preventative and restorative services to the children of Members (qualified indigent patients). Severe cases of decay and neglect will be referred to a periodontist for management. The Dental Clinic will schedule appointments for the child's dental care. Cleanings and sealants are provided through Amarillo College.

Medically Indicated Dentistry:
Medically necessary dental services will be provided by a dentist, oral surgeon, or other licensed practitioner of the dental health arts, when determined to be the treatment of choice or to be an essential part of an overall treatment plan for a medical condition. That such a condition qualifies as medically necessary is determined by a J. O. Wyatt Community Health Center physician in consultation with the Dental Clinic dentist.

SERVICES NOT COVERED BY THE WYATT HEALTH PLAN

• PRIMARY EXAMINATIONS TO ESTABLISH THE PRESENCE AND CHARACTERISTICS OF DISABILITY (such as Social Security Disability).
• Second opinions, unless at the request of the Review Organization or the attending physician (Medical Director or Indigent Care Coordinator approval required.)
• Non-emergency services in facilities other than those designated by the Wyatt Health Plan
• Services and supplies not necessary for diagnosis and/or treatment
• Custodial care
• Chronic mental illness (maintenance)
• Mental retardation (primary medial care excepted)
• Home physician services
• Treatments covered by worker's compensation, Medicaid, Medicare, or other benefit plans or resources
• Medicare, or other benefit plans or resources
• Private inpatient hospital rooms unless medically necessary or for the convenience of the hospital
• LDRP Obstetrical Services, unless at the convenience of the hospital
• Physical therapy beyond acute care or acute rehabilitation or exceeding 20 visits per calendar year
• Recreational therapy
• Services of private duty or special duty nurses
• Hypnosis, biofeedback or other such special treatments not specifically listed as a covered benefit
• Cosmetic surgery, unless it is required for emergent repair of an accidental injury or required for restoration of the function of a malformed body part
• Abortions, except when the mother's life would be endangered by carrying the infant to term
• Fertility studies and treatment
• Impotence studies and treatment
• Vasectomy reversal and tubal reversal
• Sex change operations
• Circumcision, unless medically indicated
• Organ transplants
• Treatments determined by Review Organization or a contracted Wyatt Health Plan physician or nurse practitioner as no longer effective.
• Routine eye examinations
• Prescription lenses
• Hearing aids
• Treatment of flatfoot conditions, or subluxations of the foot
• Treatment of mycotic nails unless in a diabetic patient
• Prosthetic devices and appliances unless specifically approved by the Medical Director or Indigent Care Coordinator if necessary to prevent serious complications of a medical condition
• Services and supplies not considered to be medically necessary
• First aid supplies
• Artificial or mechanical hearts or xenografts
• Medical services and supplies determined to be experimental or investigational
• Transportation services to a long-term care facility outside the Amarillo Hospital District Services provided outside of the United States
• Services of a certified surgical assistant, chiropractor, optometrist or any category of healthcare provider not authorized to practice within the Northwest Texas Healthcare System.
• Any services not specifically listed under "Summary of Benefits" in this booklet

WYATT HEALTH PLAN LOCATIONS

Northwest Texas Hospital
1501 South Coulter
Amarillo, Texas 79106
(806) 354-1000

Financial Needs Assessment
1200 Wallace Blvd.
Amarillo, Texas 79106
(806) 354-1020

Dental Clinic
1200 Wallace Blvd.
Amarillo, Texas 79106
(806) 354-1008

J. O. Wyatt Community Health Center
1411 E. Amarillo Blvd.
Amarillo, Texas 79107

Appointment Desk: (806) 351-7201
Pharmacy: 351-7240